Assessment of hemoglobin response to iron folate supplementation and associated factors among pregnant women attending public hospitals in Addis Ababa, Ethiopia: A prospective follow-up study

doi:10.21203/rs.3.rs-5319368/v1

Background

Iron-folate supplementation is a common recommended strategy for reducing the incidence of anemia in pregnant women. However, studies on the hemoglobin response to iron folate supplementation and factors associated with the effectiveness of the intervention in developing countries, including Ethiopia, are limited.

Objective

This study aimed to assess the hemoglobin response to iron folate supplementation and associated factors among pregnant women attending public hospitals in Addis Ababa, Ethiopia.

Methods

A prospective follow-up study was conducted in public hospitals in Addis Ababa between May 1, 2023, and March 30, 2024. A total of 410 participants were selected via systematic random sampling. The data collection methods included participant interviews, medical record reviews, laboratory tests, and anthropometric assessments. Statistical analyses were carried out via SPSS Version 27. Descriptive statistics were used to describe the profile of the study participants. A p value of less than 0.05 was considered statistically significant. Logistic regression analysis was performed, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated to identify significant associations.

Results

A total of 59.7% of pregnant women exhibited an inadequate hemoglobin response to iron-folate supplementation, and 17% remained anemic despite supplementation. Early ANC booking (AOR = 3.9, 95% CI: 2.4–4.2), iron-folate intake for more than two months (AOR = 2.6, 95% CI: 1.6–4.2), adequate dietary diversity (OR = 3.4, 95% CI: 2.1–5.6), and primiparity (OR = 2.4, 95% CI: 1.4–4.2) were significantly associated with an adequate hemoglobin response.

Conclusion

The response of hemoglobin to iron-folate supplementation is low. Promoting early antenatal care, prolonged iron-folate supplementation, and ensuring adequate dietary diversity are crucial to improve the hemoglobin response in pregnant women. Efforts to increase awareness and accessibility to these key factors can help reduce the burden of anemia during pregnancy and improve maternal and fetal health outcomes.

Anemia

hemoglobin level

iron deficiency

iron-folate supplementation

pregnancy

Anemia, a major public health issue affecting maternal and child health, is highly prevalent in low-income countries, particularly among pregnant women. Anemia affects approximately 38% of pregnant women worldwide, contributing to maternal morbidity and mortality, as well as adverse pregnancy outcomes such as preterm delivery and low birth weight [1]. The most common cause of anemia during pregnancy is iron deficiency, which can be addressed through supplementation with iron and folic acid. In Ethiopia, anemia remains a significant problem, with an estimated 38% of pregnant women affected [2].

Iron and folate supplementation during pregnancy is a widely recommended intervention to prevent and treat anemia, with proven benefits in improving maternal hemoglobin levels and reducing the risk of maternal anemia and its complications [3]. Despite these known benefits, the effectiveness of iron-folate supplementation can be influenced by several factors, including the woman’s baseline hemoglobin level, compliance with supplementation, dietary practices, gastrointestinal side effects, elevation of residence and the presence of underlying health conditions such as infections or chronic diseases [4, 5].

In Ethiopia, iron-folate supplementation has been part of the national antenatal care (ANC) package, with efforts to improve coverage and adherence [6]. However, studies show that compliance with supplementation and the overall impact on maternal hemoglobin levels remain suboptimal, raising concerns about the adequacy of the intervention and the need to assess other contributing factors [7]

Given the diverse factors that influence the hemoglobin response to iron-folate supplementation, a comprehensive assessment is crucial to optimize the effectiveness of the intervention. This study aimed to assess the hemoglobin response to iron-folate supplementation and identify associated factors among pregnant women attending public hospitals in Addis Ababa, Ethiopia. By understanding the factors that affect the hemoglobin response to iron-folate supplementation during pregnancy, this study could contribute to improving maternal health outcomes and informing strategies to enhance the implementation of supplementation programs.

Study period and setting

The study was conducted in selected public hospitals in Addis Ababa, the capital of Ethiopia, from May 1, 2023, to March 30, 2024. Among the twelve government hospitals, three hospitals, namely, Zewditu Memorial Hospital, St. Paul’s Millennium Hospital Medical College and Menelik Hospital, were selected via a simple random sampling technique. Pregnant women attending ANC units in the aforementioned hospitals were the study participants. The city has a projected population of 3,603,000, and 49.97% are females, 34.4% of whom are in the reproductive age group, according to the 2019 CSA projection [8]. The city lies at an elevation of 2355 meters above sea level.

Study Design

An institution-based prospective follow-up study design was used for pregnant women attending antenatal care units in the selected public hospitals in Addis Ababa from May 1, 2023, to March 30, 2024.

Population

Source population

All pregnant women above 18 years of age who have ANC booked at the selected public hospitals in Addis Ababa, Ethiopia, were included.

Study population

All randomly selected pregnant women who were above 18 years of age had ANC booking during the time of data collection at each selected public hospital in Addis Ababa, Ethiopia.

Eligibility criteria

Inclusion criteria

Women with singleton pregnancies above 18 years of age signed the written informed consent form, started IFAS with Hb levels > 7 mg/dl, and had ANC follow-up at the selected public hospitals during the time of data collection in Addis Ababa, Ethiopia.

Exclusion criteria

Women with severe anemia initially and throughout pregnancy (Hb < 7 mg/dl), blood transfusion, smoking, comorbid conditions, including but not limited to HTN, DM, CKD, known hematologic disorders, and infections, including helminthiasis, HIV and malaria, were included.

Sampling technique and procedure

On the basis of previous hospital records, the total number of pregnant women who had ANC follow-up at each selected hospital (within a month before the start of data collection) was obtained. This was followed by a proportional allocation of the number of ANC attendees to the respective hospitals. Using the ANC registry in the respective hospitals as a sampling frame, a systematic random sampling method was employed to select pregnant women who had ANC booking at the selected public hospital (Fig. 1). Pregnant women receiving ANC services at each selected public hospital during the data collection/study period who met the inclusion criteria had a random chance of being approached. The interviews were performed until the required sample size of 410 was achieved. Consent was secured verbally and in written form before the start of the data collection.

Variables of the study

Dependent variable

Maternal blood hemoglobin levels.

Independent variable

Sociodemographic factors (age, occupation, educational status, marital status, household size), MUAC, birth interval, parity, stage of pregnancy, maternal blood group, timing of ANC booking, IFAS adherence, duration of intake of IFAS, planned or unplanned pregnancy, and dietary diversity score.

Operational definitions

Anemia was defined as a hemoglobin value of less than 11 g/dL [9]. Hemoglobin responses to IFA supplementation were categorized as either adequate or inadequate [5, 10]. The criteria for these categories were as follows:

Adequate response: An increase in the hemoglobin value of at least 1 g/dL after a minimum of one month of supplementation, indicative of iron deficiency [11, 12].

Inadequate response: A change in the hemoglobin value of less than 1 g/dL after a minimum of one month of IFA supplementation. This response suggests the presence of functional iron deficiencies [5].

The normal reference range for hematological parameters, depicted below, was used: [13]. The severity of anemia was classified as follows: mild anemia (Hb: 10–10.9 g/dl), moderate anemia (Hb: 7–9.9 g/dl), and severe anemia (Hb < 7.0 g/dl) [1]. Gestational ages were categorized into the first trimester (1–14 weeks), second trimester (15–28 weeks) and third trimester (29 and above) using WHO classification criteria. Pregnant women with a MUAC value of 23–33 cm were considered to have normal nutritional status; those with MUAC measurements < 23 cm were categorized as undernourished, and those above 33 cm were categorized as obese [14, 15].

Compliance with the IFA supplement was assessed on the basis of pill count and self-reported methods. Women who took 70% or more of the IFA tablets, equivalent to taking at least 5 days a week throughout the study period, were considered adherent [16], using recording, self-reporting, pill counting and checking their cards. Otherwise, participants were considered nonadherent and excluded from the study.

Dietary intake was assessed via a food frequency questionnaire using the minimum dietary diversity for women (MDD-W), which was adopted by the Food and Agricultural Organization of the United Nations. The minimum dietary diversity for women (MDD-W) is a population-level indicator of diet diversity validated for women aged 15–49 years. It is a dichotomous indicator based on 10 food groups consumed locally (in this case, in Ethiopia) and is considered the standard for measuring population-level dietary diversity in women of reproductive age [17]. Pregnant women who consumed five or more food items in the last 24 hours, out of the 10 food groups, were considered to have adequate dietary diversity; otherwise, they were considered to have poor dietary diversity (Fig. 2).

Data collection procedures, tools and quality control

Data collection tools

A structured questionnaire was prepared in English and Amharic. The Amharic version was completed by the participants if they were able to read and write in the Amharic language; otherwise, the data collector completed the questionnaire by asking the respondents. The response was subsequently translated back into English. The questions explored and addressed the respondent’s sociodemographic profiles, data on parity/gravidity, intake of IFAS and dietary diversity.

Data collection procedure and quality control

Pregnant women who met the inclusion criteria were prescribed 60 mg of elemental iron plus 400 µg of folic acid oral tablets once daily if nonanemic and 120 mg of elemental iron plus 800 µg of folic acid once daily if anemic. The blood hemoglobin level of the participants was measured two times, i.e., at the first ANC visit (baseline, before the start of IFA supplementation) and after the intake of iron folic acid tablets, at the endpoint of the follow-up. All the respondents were taking similar iron‒folic acid tablets throughout the follow-up period.

A 5 mL venous blood sample was collected from respondents while they were seated comfortably, using iron-free heparinized test tubes. Professional nurses conducted the procedures at each respective hospital. Hematological assessments were performed at both the baseline and the end point (after at least 4 weeks of IFAS supplementation). All standard precautions were strictly adhered to during and after blood collection. Hematological analysis was conducted via a Mindray Auto Hematology Analyzer (Mindray Biomedical Electronics Co. Ltd., China), with quality control measures rigorously followed according to the manufacturer’s guidelines.

Mid‒upper arm circumference was measured via non-stretchable measuring tape according to the WHO recommendations to assess the participants’ nutritional status. Blood pressure was measured at the endpoint after iron folate supplementation in both arms, in a position where the brachial artery at the antecubital fossa is at the heart level.

Data were collected by the investigators assigned at each chosen hospital. To ensure the completeness, accuracy and consistency of data collection and for the investigators to have a common understanding of how to approach the participants, training was given before the start of data collection by the main investigator. On-site supervision was carried out weekly by the principal investigator. A pretest was performed at Abebech Gobena MCH Hospital, Addis Ababa, on 10% of the sample to check for the accuracy of the responses, language clarity, and appropriateness of the tools. Following the pretest, some adjustments were performed, including typing errors being fixed, data collectors being reoriented, and questionnaires being rearranged.

Data processing and analysis

The completeness and consistency of the data were checked. The data were then entered into EpiData version 4.6 software. After the data were edited and coded, they were exported to SPSS version 27 software for further analysis. Descriptive statistics were used to describe the profile of the study participants and to determine the hematological indices of the pregnant women enrolled in the study. Ninety-five percent CIs and corresponding P values < 0.05 were used to declare statistical significance. A logistic regression model was fitted to identify the associated variables.

Sociodemographic characteristics of the study participants

Four hundred ten subjects participated in the study, for a response rate of 100%. The age of the study subjects ranged from 19–43 years, with a median age of 30 years and an IQR of 34–26 years. The majority of the respondents attended secondary school (261 (63.7%)), whereas 395 (96.3%) of the respondents were permanent urban residents. Unemployed respondents accounted for 274 (66.8%) of the participants. Most of the respondents were married (90.5%) (Table 1).

Table 1

Sociodemographic characteristics of pregnant women attending antenatal care units in selected public hospitals in Addis Ababa, Ethiopia, from May 1 to March 30, 2023 (n = 410)
Variables	Category	Frequency	Percentage
Age in years*	< 20	4	1
	20–29	189	46.1
	30–39	209	51
	> 40	8	2
Residency	Urban	395	96.3
	Rural	15	3.7
Occupation	Employed	136	33.2
	Unemployed	274	66.8
Marital status	Unmarried	39	9.5
	Married	371	90.5
Household Size	1–5	384	93.7
	> 5	26	6.3
Educational Status	No formal education	11	2.7
	Attended Primary school	45	11
	Attended Secondary school	261	63.7
	Higher education	93	22.7

*Age category was adopted from a previous research article [6].

Clinical characteristics of the study participants

Most of the participants (58.8%) were in their third trimester of pregnancy (i.e., at the end of the follow-up) with multiparity (54.4%), and more than half of the participants started ANC booking in the early first trimester. The majority of the respondents (80.5%) had a birth interval of more than 2 years. Two hundred eighty-five respondents reported that their pregnancy was planned and that more than half of the respondents had been taking IFAS for ≥ 2 months. The most common times for IFAS and coffee/tea intake were after meals (53.7% and 71%, respectively). Over half of the respondents (56.8%) had adequate MDD-W. Approximately three-fourths of the participants had MUAC measurements within the normal range of 23–33 cm (Table 2).

Table 2: Clinical characteristics of pregnant women attending antenatal care units in selected public hospitals in Addis Ababa (n=410)

ANC booking ***	Early First Trimester	222	54.15
	Late First Trimester	188	45.85
coffee/tea intake	After meal	291	71
	Before meal	52	12.7
	No time preference	67	16.3
pregnancy planned or not	Yes	285	69.5
	no	125	30.5

*MDD-W = Minimum Dietary Diversity for Women, **MUAC: Mid Upper Arm Circumference, adopted from a research article [15].

***Early first trimester: < 7 weeks after conception, late first trimester ≥ 7 weeks after conception

Hematological responses to IFA supplementation

An adequate Hb response, an increase in hemoglobin level by 1 g/dl and above, was found in 40.7% of the respondents who underwent IFA. Before IFA supplementation, more than one-third of the pregnant women (39.3%) were diagnosed with anemia (Hb < 11.0 g/dl). After supplementation, this percentage decreased to 17.3% (p = 0.001). Sixty-three participants (15.3%) who were anemic before IFAS initiation also remained anemic after supplementation. Eight pregnant women with normal baseline hemoglobin levels developed anemia despite intake of IFAS.

Factors associated with the hemoglobin response to IFA supplementation

The variables that were found to have a corresponding p value less than 0.25 via bivariate logistic regression and hence were entered into multivariable logistic regression analysis were marital status, planned or unplanned pregnancy, parity, MDD-W, duration of IFAS intake, the timing of ANC booking, experiencing side effects of IFAS and the number of tablet intakes per week (intermittent intake or continuously all days of the week for the duration of the supplementation) (Table 3).

Table 3: Multivariable binary logistic regression of factors associated with the Hb response to iron folate supplementation among pregnant women attending antenatal care units in Addis Ababa public hospitals.

Duration of IFAS intake
>=2 months	110	96	2.95(1.96– 4.5)	2.6(1.6–4.2)	0.001
1–2 months	57	147	1	1
Side effects from IFAS
Yes	81	159	0.49(0.3–0.7)	0.5(0.3–0.8)	0.007
No	86	84	1	1
Tablet intake per week
>5 tabs	142	155	3.2(1.96–5.30)	2.3(1.3–4.1)	0.005
<=5 tabs	25	88	1	1
MDD-W
Adequate	147	30	2.55(1.7–3.8)	3.4(2.1–5.6)	0.001
Inadequate	96	137	1	1
ANC: antenatal care, AOR: adjusted odds ratio, COR: CI: confidence interval, crude odds ratio, IFAS: iron folic acid supplementation, MDD-W: minimum dietary diversity for women

Among all the variables included in the multivariable logistic regression analysis, MDD-W, the timing of ANC booking, the duration of IFAS intake, the average number of tablets consumed per week, parity and experiencing IFA side effects were significantly associated with the main outcome variable (adequate Hb response after supplementation) after adjustment for confounding factors (Table 3).

The respondents who took IFA tablets for more than two months were 2.6 times more likely to have adequate hemoglobin responses than were the respondents who took them for a duration of 1–2 months (AOR = 2.6, 95% CI (1.6–4.2)). Additionally, pregnant women who reported that they had side effects from IFA intake were less likely to have an adequate response to IFA supplementation than were those who did not experience side effects. (AOR = 0.5, 95% CI = 0.32–0.84). Furthermore, pregnant women who are adherent to IFAS are 2.28 times more likely to have an adequate hemoglobin response to iron folate supplementation than nonadherent respondents are (AOR = 2.28, 95% CI = 1.28–4.1). This study also revealed that primiparous respondents were 2.4 times more likely to have an adequate Hb response to iron folate supplementation than multiparous respondents were (AOR = 2.4, 95% CI (1.4– 4.2)) (Table 3).

Pregnant women with adequate minimum dietary diversity for women (MDD-W) were 3.4 times more likely to have an adequate hemoglobin response than those with inadequate MDD-W were (AOR = 3.4, 95% CI = 2.12–5.56) (Fig. 2). Additionally, pregnant women who booked for antenatal care at the health facility in the first seven weeks of the first trimester were 3.9 times more likely to have an adequate hemoglobin response to iron-folate supplementation than respondents who booked in later gestational weeks were (AOR = 3.9, AOR = 2.41–6.56).

The study revealed that an adequate hemoglobin response to iron-folate supplementation was present in only 40.7% [95% CI: 35.9% − 45.5%) of the respondents. This result is in line with a study performed in Jordan (43.1%) [18] but lower than a study conducted in Mekelle, Ethiopia (48.5%) [5], and a study of five RCTs [12]. This difference could be due to differences in geographical location, which can influence the body's iron metabolism and the overall effectiveness of the supplementation program. Compared with the Mekelle, the higher altitude of Addis Ababa could necessitate greater physiological adaptations, thereby impacting the hematological response to iron-folate supplementation differently. According to other studies, oral iron therapy could increase hemoglobin levels, with near-maximal response rates achievable by day 28 postsupplementation. A ≥ 1.0 g/dL increase in hemoglobin after 2 weeks of oral iron therapy has been shown to be an accurate predictor of subsequent hemoglobin responses at 6–8 weeks [12].

The respondents with adequate dietary diversity scores were 3.4 times more likely to have an adequate hemoglobin response to iron folate supplementation than were the respondents with inadequate dietary diversity (AOR = 3.4, 95% CI (2.12–5.56)). This result is consistent with those of previous studies conducted in southern Ethiopia [19], North Shewa [20] and Ghana [21] but not with those of another study conducted in Ghana [22]. The difference with the latter study, which was performed in Ghana, could be because of the inclusion of a population with better baseline nutritional status, which could mask the effects of dietary diversity on the hemoglobin response.

In this study, respondents who booked for antenatal care in the first half of the first trimester and hence started IFAS earlier had a better hemoglobin response to iron folate supplementation than those who booked in the latter half of the first trimester did (AOR 3.9, 95% CI 2.41–6.56). Similar findings have been reported in other studies conducted in Nigeria [23] and South Africa [24]. Studies have shown that iron supplementation during the period of organogenesis, i.e., during the first 3–8 weeks of gestation, could have a teratogenic effect and that supplementation should not be given during this period [25]. Despite this, in a setting where anemia prevalence is high, it is recommended that pregnant women start iron folate supplementation as early as possible after conception [1, 26].

Primiparous respondents were 2.4 times more likely to have an adequate Hb response to iron folate supplementation than multiparous respondents were (AOR = 2.4, 95% CI (1.4– 4.2)). The results of this study follow many reports [27, 28] but are not in line with other studies that reported a reduction in the risk of anemia with high parity [29, 30]. Our findings are also consistent with a prospective follow-up study reporting that anemia and low serum ferritin levels occur more commonly in multiparous patients than in nulliparas [31]. This finding is also supported by a prospective cohort study conducted in Oman, Asia [32]; a prospective observational study performed in Japan [33]; and several cross-sectional studies conducted in Pakistan [34], India [35] and Ghana [36]. Despite supplementation, a progressive decline in the mean Hb concentration secondary to greater acceleration of plasma volume expansion has also been reported in women with multiparity [37].

In this study, respondents who took the supplement for a duration of two months or more were 2.6 times more likely to have an adequate hemoglobin response to iron folate supplementation than respondents who took it for 1–2 months (AOR 2.6, 95% CI (1.6–4.2)). This finding is consistent with a study performed in Kenya [38] but not with a study performed in North Ethiopia [5]. The difference with the latter study might be due to differences in baseline nutritional status between populations, which can affect the efficacy of the supplementation.

Compared with those who took 5 or fewer tablets per week intermittently, those who took more than five iron folate tables per week on consecutive days were 2.28 times more likely to have an adequate change in hemoglobin level (AOR 2.28, 95% CI (1.28–4.1)). This finding is in line with a previous study [38]. In an RCT involving 200 participants, no differences in hemoglobin, serum ferritin or reticulocyte count were reported between alternate-day oral iron supplementation and daily supplementation [39, 40]. However, the results of this study are not consistent with those of previous studies that assessed whether daily oral iron intake precedes anemia over intermittent intake of iron and reported inconclusive results [39, 41]. Additionally, this result contradicts the findings of previous studies, including a randomized controlled trial, which revealed that providing iron supplements daily in divided doses increases serum hepcidin and hence reduces iron absorption [42]. This study revealed that providing iron supplements on alternate days and in single doses optimizes iron absorption and might be a preferable dosing regimen. Another study with results that contradict those of our study is a randomized controlled trial that showed that alternate-day dosing resulted in greater fractional iron absorption than consecutive-day dosing [43].

Compared with those who did not complain of side effects, participants in this study who reported experiencing side effects/s of iron folate supplementation had a poor hemoglobin response. Pregnant women who experienced side effects from IFAS were approximately half as likely to have an adequate hemoglobin response than those who did not experience side effects from IFAS (AOR = 0.5 95% CI 0.32–0.84) (Table 3). This might be a result of not taking iron folate pills as per the guidelines because of side effects. Intermittent regimens of IFA tablets have been reported to have fewer side effects than daily supplementation does [44].

This study revealed that iron-folate supplementation was ineffective in preventing anemia in a substantial proportion (17%) of women and resulted in an inadequate hemoglobin response in nearly 60% of the participants. Dietary diversity, an earlier timing of ANC booking, a duration of IFAS intake of more than 2 months, good compliance with iron folate supplementation, and primiparity were significantly associated with adequate iron folate supplementation.

ANC Ante Natal Care

AOR Adjusted Odds Ratio

CSA Central Statistical Agency

CI Confidence Interval

EDHS Ethiopia Demography and Health Survey

EPHI Ethiopian Public Health Institute

FPN Ferroportin

FMOH-E Federal Ministry of Health, Ethiopia

GA Gestational Age

Hb Hemoglobin

IDA Iron Deficiency Anemia

IFAS Iron-Folic Acid Supplementation

MDD-W Minimum Dietary Diversity for Women

OR Odds Ratio

SPHMMC St. Paul’s Millenium Medical College

WHO World Health Organization

Acknowledgements

We extend special thanks to the health professionals in the respective hospitals for their invaluable data collection efforts. We are grateful to the study participants for their time and willingness to participate in the study, which made this research possible. Additionally, we acknowledge the cooperation and support recieved from the respective hospitals throughout the data collection process.

Funding: The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors for undertaking this study.

Clinical trial number: Not applicable.

Author contributions

ZEA, AAL and DHW conceptualized and designed the study. ADG and HAA were involved in the implementation and data collection for the study. ZEA, ADG and HAA were involved in data cleaning and formal analysis. ZEA wrote the first draft of the manuscript. AAL and DHW were involved in a thorough critical review of the manuscript drafts. All authors have read and approved final version of the manuscript.

Data availability

The data that support the findings presented in this study is available from the corresponding author upon reasonable request.

Ethical approval and consent to participate

This study received ethical approval from the Addis Ababa City Health Bureau (Reference number: A/A/12240/227), and Saint Paul's Millennium Medical College (Reference Number: Pm23/1024). All participants provided informed consent after being fully informed about the study's purpose and their right to withdraw at any time. To ensure confidentiality, participant names were replaced with codes, and data were used solely for research purposes. The study adhered to the principles of the Helsinki Declaration.

Consent for publication: Not applicable.

Competing interests: The authors declare no competing interests

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No competing interests reported.

Assessment of hemoglobin response to iron folate supplementation and associated factors among pregnant women attending public hospitals in Addis Ababa, Ethiopia: A prospective follow-up study

Status:

Version 1

Abstract

Background

Objective

Methods

Results

Conclusion

Figures

INTRODUCTION

METHODS

Study period and setting

Study Design

Population

Source population

Study population

Eligibility criteria

Inclusion criteria

Exclusion criteria

Sampling technique and procedure

Variables of the study

Dependent variable

Independent variable

Operational definitions

Data collection procedures, tools and quality control

Data collection tools

Data collection procedure and quality control

Data processing and analysis

RESULTS

Sociodemographic characteristics of the study participants

Clinical characteristics of the study participants

Hematological responses to IFA supplementation

Factors associated with the hemoglobin response to IFA supplementation

DISCUSSION

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1